Complete Report

Summary

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Jeremy Moore, a team leader for the Office of Evaluation and Inspections in Dallas, is interviewed by Lyndsay Patty, a team leader for the Office of Evaluation and Inspections.

WHY WE DID THIS STUDY

From 2008-2012, we conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a Congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, we developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various health care stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.

HOW WE DID THIS STUDY

This study estimates the national incidence rate, preventability, and cost of adverse events in SNFs by using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care. Sample beneficiaries had SNF stays of 35 days or less.

WHAT WE FOUND

An estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.

WHAT WE RECOMMEND

Because many of the events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events. Therefore, we recommend that AHRQ and CMS raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts. This would include collaborating to create and promote a list of potential nursing home events-including events we found that are not commonly associated with SNF care-to help nursing home staff better recognize harm. CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events. AHRQ and CMS concurred with our recommendations.